Provider Demographics
NPI:1962139303
Name:OPETT, GARY JOSEPH
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:JOSEPH
Last Name:OPETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3271 FLOWERS RD S APT Q
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5687
Mailing Address - Country:US
Mailing Address - Phone:850-217-0108
Mailing Address - Fax:
Practice Address - Street 1:1750 HUDSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6331
Practice Address - Country:US
Practice Address - Phone:770-507-7732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist